Implementation science: Current state and how we can

move the needle Anne Sales, PhD RN

Department of Learning Health Sciences, University of Michigan

Center for Clinical Management Research, VA Ann Arbor Healthcare System

Poll #1:

• Who is in the audience? (select all that apply) • Have previously done implementation research

• Working on a newly funded QUERI program

• New to implementation research

• Operations partner working with a QUERI team

• Have not previously done implementation research

A couple of notes

• Not planning to talk about evaluation methods

• Will focus on work outside the US as well as within US • The nature of implementation-focused discourse within the US is different

from discourse outside the US

Defining implementation in health care

• Implementation of evidence based practices in routine care • Requires behavior change

• Need to understand practice and behaviors

• Role of evidence is important but often overlooked

• Routinization and sustainability are goals, but often not the focus of implementation efforts

Complex interventions and complex implementation • Considerable guidance from groups in the UK on developing complex

interventions in health care • Interventions that require action by more than one provider/clinician and/or

single patient

• Interventions that require system action or change

• How complex implementation will be is hard to know • Emerging diagnostic tools

• Focus on the individual level and levels above the individual

• Complex adaptive systems require complex implementation– probably Reference: Complex interventions in health: An overview of research methods; eds. Richards and Rahm Hallberg; Routledge 2015

61 frameworks and counting

• 2012 systematic review of the literature in dissemination and implementation sciences found over 100 frameworks • 61 identified as being potentially useful in either dissemination or

implementation or both

• Level of focus (individual, organizational, social) identified • Policy interventions would likely be at social level, above individual and probably

organizational

• But not all frameworks are equal • Some are consolidations of the literature at previous points in time

• Have other important features

• Consolidated Framework for Implementation Research (CFIR)

• Theoretical Domains Framework (TDF)

One possible systematic approach

Deciding what to implement: choosing a practice to focus on

• What is most important? • Figuring out criteria for making this determination

• Feasibility

• Burden to patients and/or providers

• How are people doing?

• What is their current performance?

• How does it compare with ideal?

• Do you have data to understand this?

• These should all factor into decision about what to implement

Understand the literature

• What evidence base is there for approaches to address the problem? • Reviewing the literature

• Systematic review and other types of review as appropriate and feasible

Intervening to implement a new practice

• Begin by understanding the bundle of behaviors and decisions that constitute that practice • Map it out

• Process mapping • Understanding how processes contribute to outcomes

• Identify practices that need intervention

• Identify influences above the level of the individual

• Practice mapping • Mapping out the practices under consideration for intervention

• Understand what behaviors make up the practices

• Understand decision points

• Root cause analysis • Mapping out the causes of failures and safety problems

• Can be used as an approach to mapping causes more generally

Systematizing design of implementation interventions • Systematic analysis of barriers (and enablers) through pilot work or

literature review

• Use of design-oriented frameworks to map barriers to behavior change techniques or implementation strategies • Individual level

• Barrier assessment through TDF

• Map to Behavior Change Techniques (http://www.bct-taxonomy.com/resources )

• Organizational level (and possibly above) • Barrier assessment through CFIR

• Map to implementation strategies (work ongoing)

• http://cfirguide.org/techniques.html

Behavior change techniques

• 93 techniques for changing behavior • Operate through specific psychological or social theory

• Emphasize specific behavior within practices

• Generally validated through both theory and empirical test

• Linked to TDF domains

• Examples • Self-monitoring of behavior (linked to Motivation and Goals)

• Instruction on how to perform a behavior (linked to Knowledge)

Reference: Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M. P., Cane, J. & Wood, C. E. (2013). The Behavior Change Technique Taxonomy (v1) of 93 Hierarchically Clustered Techniques: Building an International Consensus for the Reporting of Behavior Change Interventions. Annals of Behavioral Medicine, 46(1), pp. 81-95. doi: 10.1007/s12160-013-9486-6

Implementation strategies

• 73 broader, more macro approaches • Quite variable in level

• Linkage to 39 CFIR constructs currently in progress

• Example • Audit and provide feedback (?linked to Goals and Feedback)

• Mandate change (?linked to Leadership Engagement)

Reference: Powell et al. Implementation Science (2015) 10:21 DOI 10.1186/s13012-015-0209-1

Designing interventions

• Current leading edge in implementation research • Linking barriers to techniques (at individual level)

• Linking barriers to strategies (at higher level)

• Designing interventions from strategies (broad) and techniques (micro) as indicated

Example: Implementing an evidence based practice in an ICU

Problem: Patients are on mechanical ventilation for a long time

• Longer than other comparable units

• Long term outcomes are poor • High mortality • Loss of functional status • Long term impairment

• ABCDE evidence based bundle for improvement • Spontaneous Awakening trials • Spontaneous Breathing trials • Coordination of these two • Delirium assessment • Early mobilization

Going from barrier assessment to behavior change technique (using TDF)

• Barrier: Nurses are not sure they have the skills to handle initial attempts at spontaneous awakening • Barriers: Skills, self-efficacy, action planning

• Behavior change techniques: • Goal/target specified: behavior or outcome

• Monitoring/self-monitoring

• Graded tasks

• Social processes of encouragement, support

• Prompts, triggers, cues

More barriers to implementation

• Barrier: Providers are unaware of their actual performance • Lack of motivation/goals

• Behavior change techniques: • Goal/target specification

• Contract

• Feedback

• Rewards and incentives

• Persuasive communication

• Information about behavior and outcomes

Consider possible strategies (using CFIR)

• What are the overall goals of the hospital? • How does this ICU fit into the hospital as a whole?

• Key issues: • Staffing

• Continuity of care

• Morale

• Previous attempts to change practice

• Resources

• Leadership support

• Organizational readiness to change

Designing an intervention

• Most relevant issues are self-efficacy on the part of nurses, lack of performance awareness by all staff • Intervention could include

• Feedback component: Audit with feedback • Ensure that people know what the current status is and what patient outcomes are

• Specifying the goal or target for improvement: Goal setting or action planning

• Ensuring they know how they are doing in meeting that target

• Social processes of encouragement and support

• Leadership engagement and coaching: Mandating change

Take away messages

• Key factors influence our ability to readily move evidence-based innovation into practice settings • Patient level factors pose different issues, some of which are analogous

• Systematizing our approaches to assessing probable barriers (and facilitators) is important

• There are emerging approaches that have advantages • Frameworks and theories that link to action (prescribing approaches) rather

than description are more useful for intervention design

• Planning is essential

References • Abraham C, Michie S. A taxonomy of behavior change techniques used in interventions. Health Psychol.

2008 May;27(3):379-87. doi: 10.1037/0278-6133.27.3.379. PubMed PMID: 18624603.

• Cane J, O’Connor D, Michie S. Validation of the Theoretical Domains Framework for use in behavior change and implementation research. Implement Sci. 2012 7:37 http://www.implementationscience.com/content/7/1/37

• Chaudoir SR, Dugan AG, Barr CH. Measuring factors affecting implementation of health innovations: a systematic review of structural, organizational, provider, patient, and innovation level measures. Implement Sci. 2013 Feb 17;8:22. doi: 10.1186/1748-5908-8-22. Review. PubMed PMID: 23414420; PubMed Central PMCID: PMC3598720.

• Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M; Medical Research Council Guidance. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008 Sep 29;337:a1655. doi: 10.1136/bmj.a1655. PubMed PMID: 18824488; PubMed Central PMCID: PMC2769032.

• Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci. 2009 Aug 7;4:50. doi: 10.1186/1748-5908-4-50. PubMed PMID: 19664226; PubMed Central PMCID: PMC2736161.

• Damschroder LJ, Lowery JC. Evaluation of a large-scale weight management program using the consolidated framework for implementation research (CFIR). Implement Sci. 2013 May 10;8:51. doi: 10.1186/1748-5908-8-51. PubMed PMID: 23663819; PubMed Central PMCID: PMC3656778.

• Hujig JM, Gebhardt WA, Crone MR, Dusseldorp E, Presseau J. Discriminant validity of a theoretical domains framework questionnaire for use in implementation research. Implement Sci. 2014 9:11 http://www.implementationscience.com/content/9/1/11

• May C. Towards a general theory of implementation. Implement Sci. 2013 Feb 13;8:18. doi: 10.1186/1748-5908-8-18. PubMed PMID: 23406398; PubMed Central PMCID: PMC3602092.

• Michie S, Fixsen D, Grimshaw JM, Eccles MP. Specifying and reporting complex behaviour change interventions: the need for a scientific method. Implement Sci. 2009 Jul 16;4:40. doi: 10.1186/1748-5908-4-40. PubMed PMID: 19607700; PubMed Central PMCID: PMC2717906.

• Michie S, Johnston M, Abraham C, Lawton R, Parker D, Walker A; "Psychological Theory" Group. Making psychological theory useful for implementing evidence based practice: a consensus approach. Qual Saf Health Care. 2005 Feb;14(1):26-33. PubMed PMID: 15692000; PubMed Central PMCID: PMC1743963.

• Michie, S, et al. “From theory to behavior: Mapping theoretically derived behavioral determinants to behavior change techniques” Applied Psychology 2008 57(4): 660-680

• Sales A, Smith J, Curran G, Kochevar L. Models, strategies, and tools. Theory in implementing evidence-based findings into health care practice. J Gen Intern Med. 2006 Feb;21 Suppl 2:S43-9. PubMed PMID: 16637960; PubMed Central PMCID: PMC2557135.

• Tabak RG, Khoong EC, Chambers DA, Brownson RC. Bridging research and practice: models for dissemination and implementation research. Am J Prev Med. 2012 Sep;43(3):337-50. doi: 10.1016/j.amepre.2012.05.024. Review. PubMed PMID: 22898128; PubMed Central PMCID: PMC3592983.

Additional US resources (not exhaustive)

• http://dissemination-implementation.org/

• https://www.gem-measures.org/Public/Home.aspx • This site is currently blocked by OI&T in VA– we are requesting that it be unblocked;

will keep you posted • For now, need to access using a non-VA computer

• http://www.queri.research.va.gov/

• http://www.queri.research.va.gov/implementation/default.cfm • To be updated within the next few months

• http://www.queri.research.va.gov/implementation/quality_improvement/default.cfm • Methods selection tool

Non-US resources (also not exhaustive)

• http://ktclearinghouse.ca/ktcanada • Being updated– advised to check back later in the fall

• http://www.ucl.ac.uk/behaviour-change • Center for Behavior Change, University College, London

• http://www.implementationscience.com/ • General web site for Implementation Science

• http://www.fic.nih.gov/researchtopics/pages/implementationscience.aspx • US but focused on international research

• http://i2s.anu.edu.au/

Books

Questions or comments? Preferred contact method:

salesann@umich.edu

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